I ate my last free lunch this month, the inevitable result of years of planning on doing just that. I had just needed a little push.
But I get ahead of the story.
Sally’s blood pressure was very high. When I last saw her (just over 6 months ago) it was perfect. I remembered congratulating her efforts at that visit. “Your blood pressure is like a teenager’s!”
What had happened?
I entered the exam room and asked Sally how she was feeling. She admitted to headaches and more fatigue.
I suggested ordering some tests and doubling her blood pressure medication.
“No, please don’t,” she mumbled. “I can’t afford any more tests. And, anyway, I don’t need them.” I waited quietly for her to continue.
“I know why my blood pressure is high. I stopped taking my medication a few months ago. I also stopped my diabetes and cholesterol pills, “ she stammered. “I felt ok for the first month, but I haven’t felt good for a while now.” Her eyes brimmed with tears.
“Why did you stop taking your medicine?” I asked gently.
She brightened up a little as she told me that her husband Bill finally got a job. He’d been looking for almost a year. Unfortunately, his new job meant that they lost their Medicaid because they no longer qualified. The new insurance offered by his work had a high-deductible. “We have to pay $3000 each year before our insurance kicks in,” she said. “I just can’t afford my pills and I’m worried sick that Bill might have another heart attack if he stops his.”
What could I possibly say? I silently fumed. In most civilized countries Sally and Bill’s medications would be covered. They wouldn’t have to make impossible choices.
I handed her a tissue and patted her gently on the back. “We’ll figure something out,” I told her. I knew that Sally and Bill were hard-working, proud people. It had taken a lot to convince them to apply for Medicaid when Bill’s company closed and he lost his job last year.
In the past I would have offered her “samples” to get her through this tough time. Samples were drugs provided for free by pharmaceutical companies to doctors’ offices. This is not so much a philanthropic gesture on the part of these companies as it as a means to allow their drugs to be tried out by doctors with the hope that those doctors will then be inclined to prescribe them. A few years ago, my office had a closet-full of drugs to dispense to patients hard on their luck. We were just like a pharmacy, but free.
Recently, the hospital decided to prohibit samples. There were many reasons for this. Meticulous logs had to be maintained with pertinent patient information, drug names and doses, lot numbers and expiration dates. It was difficult to keep track of all the drugs going in and out of the closet. We were a busy office. I’m sure I wasn’t the only doctor that tore the lot numbers off the box and gave the samples to my patients with the intention of logging it all in later. At the end of the day, with piles of papers to sign and notes to dictate, it didn’t always happen.
While most patients were grateful for the short-term help, many patients took advantage of this system that essentially provided drugs without co-pays. I could hardly blame them. Rarely, a particularly entitled patient called angrily demanding medicine, even yelling at the nurses when samples weren’t ready. “I called yesterday for my Viagra! What kind of office are you running?” one man shouted to a shocked nurse.
Nurses got tired of this system as they did most of the leg work when patients called requesting samples. They filled out the logs and brought them to the doctor to sign. They called patients to tell them when their drugs were ready. They even called the pharmaceutical representatives (“drug reps”) to request specific samples when needed – all crammed in between normal duties of caring for patients in the office.
Over time sample closet rules became even stricter. Doctors were required to physically hand samples with printed instructions directly to patients. This wasn’t a problem for patients who were being seen for an appointment, but became a challenge for the ones who phoned every month for their samples. Instead of running for a bathroom break between patients, I’d be called to hand a waiting patient their samples.
My nurse coordinated the hand-off as soon as she saw me enter my office. In a smooth delivery she retrieved the samples from the closet, called the patient from the waiting room and summoned me. I stepped out of my office, took the bag from her outstretched hand and placed it into the patient’s hand. Frequently, though, patients had “just a quick question” for me and I found myself in limbo in the hallway trying to listen while calculating when I might get my next chance to use the bathroom.
Although I felt bad for patients like Sally and Bill who needed short-term help, by the time the hospital decided to forbid drug samples, I have to admit, I was relieved. And the nurses were elated. It really wasn’t a very good system. Patients became dependent on newer and more expensive drugs (no companies sampled older, cheaper drugs). When these drug samples were no longer available (because the drug rep hadn’t made it to the office in a while to deliver them or the company stopped sampling a particular medication) many patients were without their drugs.
All of this would not be a problem if I could write for any drug I wanted. If samples ran out, I could just write a prescription. But I can’t just write a prescription for any drug I choose. Insurance companies compile lists of preferred drugs (“formularies”) that have lower copays for their clients, outlawing some drugs altogether. These lists change frequently as cheaper drugs are added and more expensive ones are removed. They also change as drug companies negotiate discounts and rebates with insurance companies to gain more favorable formulary placement.
Doctors (with the help of overworked nurses) fill out frustrating “prior authorization” forms or write letters for patients when a needed drug is no longer covered. Sometimes this works, but sometimes doctors are forced to change medications that patients have been taking for years.
It wasn’t always this complicated. When I first started practicing medicine, I did get to choose the medicine I felt was best for my patient. My professional judgment and knowledge of my patients was respected. I wrote a prescription and my patient took it to the pharmacy and it was filled.
Last week I wrote a prescription for liquid doxycycline for a child very ill with Lyme disease. It took the persistent parent countless phone calls to both her insurance company and her pharmacy just to understand the process of how she could help facilitate getting her child’s medicine. It took several calls from me to my nurse and a trip in to the office to fill out paperwork on my day off to ensure the medication would be dispensed. When it was finally approved, the copay was very high since it was not on the insurance’s preferred list.
I didn’t prescribe a fancy new drug. Doxycycline has been around a very long time. It wasn’t the child’s fault the pills were too big to swallow or that they didn’t come in an appropriate dose for his size, thereby requiring a liquid form for precise dosing.
What happened? How did the cost healthcare become so unaffordable for Americans? I don’t claim to have all the answers, but clearly part of it is the expense of drugs. I know it isn’t cheap to develop and test new drugs. But why are drugs so much cheaper in other countries?
Some of this cost lies in the expense of all of the middlemen between the drug company and the patient. Some of it is in the paper pushers hired by insurances to serve as roadblocks for cost containment. If the expense of receiving and processing all the individual requests by doctors for formulary exceptions alone was eliminated, healthcare costs could be channeled to actually take care of people’s health.
And some of the cost, alas, is the expense of marketing theses drugs to consumers and convincing doctors to prescribe them.
A few years before I began practicing medicine, doctors received gifts and even expensive trips from drug reps. By the time I graduated medical school, though, the gifts were reduced to pens and notepads advertising drugs. Now even these small trinkets are no longer allowed in my state, which is a good thing.
The one significant expense that has not yet been outlawed in my state is feeding doctors. And busy doctors are hungry and eager for an easy meal.
During my residency training, I was actually able to bring my husband with me to a “drug dinner” at a fancy restaurant for the small price of listening to short educational talk and hiring a babysitter. Paul and I were grateful for those cheap dates since we were too poor and exhausted to coordinate dinner out on our own. A free meal was motivating.
A few years ago the laws changed, prohibiting spouses from attending these dinners. I stopped going. Up until very recently, though, I still went to the drug-sponsored breakfasts and lunches delivered to my work. It was convenient, tasty and free. Not only did I not have to pack myself a lunch, but I often learned valuable information at these meals.
I worried, though, over reports that these sales pitches might actually influence prescribing practices. And as the cost of drugs skyrocketed and my patients struggled to afford them, I began to feel worse about my free meals. Was I indirectly contributing to the high cost of drugs?
For the last few years, I debated a lot about whether to attend lunches anymore. In my small practice, though, I was afraid that if I made a personal stand and stopped going that the drug reps would no longer bring food to my overworked staff. Although I was the target of their free meals, I didn’t feel like it was my place to choose for the entire office.
I don’t mean to vilify the drug reps, who are hard-working people often passionate about their drugs. They have not only taught me a lot over the years but they also have provided patient education materials and patient assistance programs to those who qualify. But in the highly competitive pharmaceutical market, pressures to sell drugs are great.
Recently, instead of educating me, many drug reps confronted me with statistics on the drugs I prescribed. “I know you prescribed our drug twice this month,” one said to me. How did he have access to my prescribing practices? I found it unnerving. Another asked (inevitably when my mouth was full of food), “Why wouldn’t you prescribe my drug?” And yet another, “How do you pick which drug to try first?” I began to get defensive. I didn’t enjoy being grilled about my prescribing practices during my lunch “break”.
Not long ago a drug rep casually told me how he and another rep I knew were vying for a bonus. They were so close, he told me. He just needed someone to write a few more prescriptions for his drug and he would win. Wink. Wink. Nudge. Nudge. Was he seriously asking me to prescribe his drug so he could win a prize? Maybe not, but it made me very uncomfortable.
Which brings me to my last free lunch.
I was far behind schedule after a “routine check up” had turned into a medical emergency. Despite serious medical symptoms, my patient had waited until his appointment (“I knew I was going to see you in a few days”) to be seen. He couldn’t afford the extra copay for an additional office visit. For the past week, Robert experienced shortness of breath so severe that he couldn’t walk more than a few feet without becoming light headed. I suspected a blood clot in his lungs, which was later confirmed when he reached the ER.
After the rescue squad whisked my patient away, I rushed breathlessly to lunch, apologizing to the drug rep that I had to eat-and-run to be ready for my full schedule of afternoon patients.
I sat down with my plate full of food, shoveling in mouthfuls as the drug rep flipped through brochures in front of me that explained why his drug was superior to the rest. I nodded, glancing frequently at the clock behind his head. I answered his probing questions politely between mouthfuls. In record time (I had become very proficient in speed eating during residency) I finished my food and pushed my chair back.
The rep took no notice and kept talking. He opened up his computer to flash me more data. My feet rapidly tapped the floor under the table, willing me to run to my office so I could at least finish one dictation from my crazy morning before the next round of patients. I pushed my chair back a little further. I tried to be polite. I knew some of his show was for his manager, sitting across the table from me.
When he still ignored my not-so-subtle body language, I waited for him to take a breath and said, “I’m really sorry, but I had an emergency this morning and am very far behind so I have to get going,” I stood up.
I took a few steps away from the table. He leapt up and blocked my path. He actually stood between me and the exit from the lunch room. “Let me just show you this one other drug real quick,” he said. Before I had a chance to refuse he had opened a new brochure and began pointing to pie charts and graphs.
I was speechless. There was no escape. He rattled on. I resented him for forcing me to be rude, but I finally had to interrupt him. “Thank you again for a delicious lunch, but I really have to go now.” Before he could stop me again, I stepped around him and darted out the room.
I admit I felt some relief. Finally, someone had pushed me to the decision I had been mulling over for years. I was done with drug sponsored lunches.
I know my decision alone will not directly impact the high cost of drugs, but at least when I commiserate with Sally about the outrageous expense of medications I won’t feel like I am part of the problem.
After all, there is no such thing as a free lunch.